Question

END-OF-LIFE ISSUES You are the home health nurse who has been seeing Phyllis Court, who has a diagnosis of lung cancer for approximately one year. Her provider recently told her that her cancer was no longer treatable; the focus of treatment will change from curative measures to symptom relief She is confused and somewhat angry with her provider. She vaguely remembers the term "palliative care" when discussing her situation with the provider but does not know what this means. Ms. Court confides that she always felt she might survive her illness but has never formally written down her wishes concerning what types of treatment she would or would not want to have. You advise her to complete an advance directive or living will. Ms. Court states she is confused and has mixed feelings about her health care wishes right now. She asks, "If I fill out this form, can I change my mind down the road?" Revised 1/20

Answer 1

Nursing care plan :-

1. Risk for Caregiver Role Strain: The state in which an individual is at high risk to experience physical, emotional, social, and/or financial burden(s) in the process of giving care to another.

May be related to :-

Inadequate or incorrect information or understanding by a primary person; unrealistic expectations

Temporary preoccupation by significant person who is trying to manage emotional conflicts and personal suffering and is unable to perceive or to act effectively with regard to patient’s needs; does not have enough resources to provide the care needed

Temporary family disorganization and role changes; feel that caregiving interferes with other important roles in their lives

Patient providing little support in turn for the primary person

Prolonged disease/disability progression that exhausts the supportive capacity of significant persons

Significant person with chronically unexpressed feelings of guilt, anxiety, hostility, despair

Highly ambivalent family relationships; feel stress or nervousness in their relationship with the care receiver

Possibly evidenced by :-

Patient expressing/confirming a concern or complaint about SO’s response to patient’s health problem, despair about family reactions/lack of involvement; history of poor relationship between caregiver and care receiver

Neglectful relationships with other family members

Inability to complete caregiving tasks; altered caregiver health status

SO describing preoccupation about personal reactions; displaying intolerance, abandonment, rejection; caregiver not developmentally ready for caregiver role

SO attempting assistive/supportive behaviors with less than satisfactory results; withdrawing or entering into limited or temporary personal communication with patient; displaying protective behavior disproportionate (too little or too much) to patient’s abilities or need for autonomy

Apprehension about future regarding care receiver’s health and the caregiver’s ability to provide care

Desired Outcomes :-

Identify resources within themselves to deal with situation.

Visit regularly and participate positively in care of patient, within limits of abilities.

Express more realistic understanding and expectations of patient.

Provide opportunity for patient to deal with situation in own way.

Nursing Interventions and Rationale :-

Assess level of anxiety present in family and/or SO - Anxiety level needs to be dealt with before problem solving can begin. Individuals may be so preoccupied with own reactions to situation that they are unable to respond to another’s needs.

Establish rapport and acknowledge difficulty of the situation for the family. May assist SO to accept what is happening and be willing to share problems with staff.

Determine the level of impairment of perceptual, cognitive, and/or physical abilities. Evaluate illness and current behaviors that are interfering with the care of the patient. Information about family problems will be helpful in determining options and developing an appropriate plan of care.

Note patient’s emotional and behavioral responses resulting from increasing weakness and dependency - Approaching death is most stressful when patient and/or family coping responses are strained, resulting in increased frustration, guilt, and anguish.

Discuss underlying reasons for patient behaviors with family. When family members know why patient is behaving differently, it may help them understand and accept or deal with unusual behaviors.

Assist family and patient to understand “who owns the problem” and who is responsible for resolution. Avoid placing blame or guilt. When these boundaries are defined, each individual can begin to take care of own self and stop taking care of others in inappropriate ways.

Determine current knowledge and/or perception of the situation. - Provides information on which to begin planning care and make informed decisions.

2. Activity Intolerance - Insufficient physiologic or physiological energy to endure or complete required or desired activity.

Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.

May be related to

Generalized weakness

Bedrest or immobility; progressive disease state/debilitating condition

Imbalance between oxygen supply and demand

Cognitive deficits/emotional status, secondary to underlying disease process/depression

Pain, extreme stress

Possibly evidenced by

Report of lack of energy, inability to maintain usual routines

Verbalizes no desire and/or lack of interest in activity

Lethargic; drowsy; decreased performance

Disinterested in surroundings/introspection

Desired Outcomes

Identify negative factors affecting performance and eliminate/reduce their effects when possible.

Adapt lifestyle to energy level.

Verbalize understanding of potential loss of ability in relation to existing condition.

Maintain or achieve slight increase in activity tolerance evidenced by acceptable level of fatigue/weakness.

Remain free of preventable discomfort and/or complications.

Nursing Interventions and Rationale

Assess sleep patterns and note changes in thought processes behaviors.Multiple factors can aggravate fatigue, including sleep deprivation, emotional distress, side effects of medication, and progression of disease process.

Recommend scheduling activities for periods when patient has most energy. Adjust activities as necessary, reducing intensity level and/or discontinuing activities as indicated.Prevents overexertion, allows for some activity within patient ability.

Encourage patient to do whatever possible: self-care, sit in chair, visit with family or friends. Provides for sense of control and feeling of accomplishment.

Instruct patient, family, and/or caregiver in energy conservation techniques. Stress necessity of allowing for frequent rest periods following activities.Enhances performance while conserving limited energy, preventing increase in level of fatigue.

Demonstrate proper performance of ADLs, ambulation or position changes. Identify safety issues: use of assistive devices, temperature of bath water, keeping travel-ways clear of furniture.Protects patient or caregiver from injury during activities.

Encourage nutritional intake and use of supplements as appropriate.Necessary to meet energy needs for activity.

Document cardiopulmonary response to activity (weakness, fatigue, dyspnea, arrhythmias, and diaphoresis). Can provide guidelines for participation in activities.

Monitor breath sounds. Note feelings of panic or air hunger. Hypoxemia increases sense of fatigue, impairs ability to function.

Provide supplemental oxygen as indicated and monitor response.Increases oxygenation. Evaluates effectiveness of therapy.

3. Anticipatory Grieving

Anticipatory Grieving: The state in which an individual or group experiences reactions in response to an expected significant loss.

Death Anxiety: The state in which an individual experiences apprehension, worry, or fear related to death or dying.

May be related to

Anticipated loss of physiological well-being (e.g., change in body function)

Perceived death of patient

Possibly evidenced by

Changes in eating habits; alterations in sleep patterns, activity levels, libido, and communication patterns

Denial of potential loss, choked feelings, anger

Fear of the process of dying; loss of physical and/or mental abilities

Negative death images or unpleasant thought about any event related to death or dying; anticipated pain related to dying

Powerlessness over issues related to dying; total loss of control over any aspect of one’s own death; inability to problem-solve

Worrying about impact of one’s own death on SOs; being the cause of other’s grief and suffering; concerns of overworking the caregiver as terminal illness incapacitates

Desired Outcomes

Identify and express feelings appropriately.

Continue normal life activities, looking toward/planning toward/planning for the future, one day at a time.

Verbalize understanding of the dying process and feelings of being supported in grief work.

Experience personal empowerment in spiritual strength and resources to find meaning and purpose in grief and loss.

Desired Family Outcome:

Verbalize understanding of the stages of grief and loss, ventilate conflicts and feelings related to illness and death.

Nursing Interventions and Rationale

Facilitate development of a trusting relationship with patient and/or family.Trust is necessary before patient and/or family can feel free to open personal lines of communication with the hospice team and address sensitive issues.

Assess patient and/or SO for stage of grief currently being experienced. Explain process as appropriate.Knowledge about the grieving process reinforces the normality of feelings and/or reactions being experienced and can help patient deal more effectively with them.

Provide open, nonjudgmental environment. Use therapeutic communication skills of active listening, affirmation, and so on.Promotes and encourages realistic dialogue about feelings and concerns.

Encourage verbalization of thoughts and/or concerns and accept expressions of sadness, anger, rejection. Acknowledge normality of these feelings.Patient may feel supported in expression of feelings by the understanding that deep and often conflicting emotions are normal and experienced by others in this difficult situation.

Be aware of mood swings, hostility, and other acting-out behavior. Set limits on inappropriate behavior, redirect negative thinking. Indicators of ineffective coping and need for additional interventions. Preventing destructive actions enables patient to maintain control and sense of self-esteem.

Monitor for signs of debilitating depression, statements of hopelessness, desire to “end it now.” Ask patient direct questions about state of mind. Patient may be especially vulnerable when recently diagnosed with end-stage disease process and/or when discharged from hospital. Fear of loss of control and/or concerns about managing pain effectively may cause patient to consider suicide.

Reinforce teaching regarding disease process and treatments and provide information as requested or

appropriate about dying. Be honest; do not give false hope while providing emotional support. Patient and/or SO benefit from factual information. Individuals may ask direct questions about death, and honest answers promote trust and provide reassurance that correct information will be given.

Review past life experiences, role changes, sexuality concerns, and coping skills. Promote an environment conducive to talking about things that interest patient.Opportunity to identify skills that may help individuals cope with grief of current situation more effectively. Issues of sexuality remain important at this stage: feelings of masculinity or femininity, giving up role within family, ability to maintain sexual activity (if desired).

Investigate evidence of conflict; expressions of anger; and statements of despair, guilt, hopelessness, inability to grieve. Interpersonal conflicts and/or angry behavior may be patient’s or SO’s way of expressing or dealing with feelings of despair and/or spiritual distress, necessitating further evaluation and support.

Determine way that patient and/or SO understand and respond to death. Determine cultural expectations, learned behaviors, experience with death (close family members and/or friends), beliefs about life after death, faith in Higher Power (God). These factors affect how each individual faces death and influences how they may respond and interact.

Assist patient/SO to identify strengths in self or situation and support systems.Recognizing these resources provides opportunity to work through feelings of grief.

Be aware of own feelings about death. Accept whatever methods patient/SO have chosen to help each other through the process.